Women in rural India who are poor, uneducated and marry early have the lowest odds of a safe birth such as in a hospital, according to a new study which analyses why for every 100,000 live births in the country's poorer states, 161 women die.
Published in the peer-reviewed journal Global Health Action, the findings provide new insights into access to maternity care in nine Indian states. In the first research of its kind, the authors also highlight failings in government interventions to reduce deaths related to pregnancy and childbirth.
Skilled support in medical institutions such as hospitals and clinics has significantly reduced maternal mortality in India. However, pregnancy-related complications remain the number one cause of death among girls aged 15 to 19 in India and this new study presents a concerning picture of the situation in the country's nine low performing states (LPS).
This study, which used a national data set including 112,518 women who gave birth in India's nine lowest performing states (constituting about half of the country's population), showed distance, disadvantage and high cost are other factors to blame for more than a quarter (26%) of women still delivering at home in LPS compared with 21% across India overall.
The authors warn cash-incentive schemes to encourage institutional births aren't working in these areas. They're calling for stronger regional policies specifically in LPS to improve current rates and outcomes.
"Despite several 'safe motherhood' programmes initiated by the government, the maternal mortality rate remains higher in LPS than the nation's average," says co-author Pintu Paul from Jawaharlal Nehru University, New Delhi, India.
"Women expressed distance or lack of transportation and costs to be challenging in accessing health facilities for the delivery. This was along with other reasons like facility closures, poor service/trust issues, and others.
"Delivery at a health institution is a key intervention to avert the risk of maternal mortality due to childbirth-related complications.
"Strengthening sub-national policies specifically in underperforming states is imperative to improve institutional delivery coverage."
In the lower performing states, the number of maternal deaths account for 12% of all global maternal deaths. In India this equates to 62% of their maternal deaths. 71% of infant deaths are seen in this area in addition to 72% of under-five deaths.
Since 1990, considerable progress has been made in reducing maternal mortality overall from 556 deaths per 100,000 to 113. India, still though, has the 56th worst rate worldwide and the 13th worst outside of Africa.
However, the government's target of 100 deaths per 100,000 has not yet been met, and the rate remains 'alarmingly high' (161 deaths per 100,000) in LPS, according to the study authors.
They analysed state-level data on maternal mortality (2016 to 2018) and information from the National Family Health Survey (NFHS) (2015 to 2016). The NFHS data involved 112,518 women aged 15 to 49 years who had delivered a living child in the five years preceding the survey.
Pregnancy complications and frequency of exposure to mass media (such as newspapers) were among the questions that the researchers asked the participants.
Access for women to the government's safe motherhood programme – Janani Suraksha Yojana (JSY) – was also examined. Launched in 2005, the JSY promotes institutional delivery by integrating cash assistance with delivery/post-delivery care for poor pregnancy women.
The research focused on states such as Bihar, Jharkhand and Uttar Pradesh where rates of women delivering their babies in medical institutions are low.
In addition to the findings on place of birth, the study highlights that women who were Muslim (62%) were less likely to deliver at a medical institution than those who were Hindu (76%) or from other castes. This was also the case for those aged 35 to 49 (60%) compared with 15 to 24-year-olds (79%).
Women who were completely exposed to mass media utilized the services the most in all the states (87%) compared to those who had no exposure at all (61%).
Co-author Ria Saha, a public health consultant in London, adds: "State-specific intervention should not only focus on increasing the number of public health facilities but also improving its associated quality of care.
"Although India has recently institutionalized midwifery care into the health system to strengthen the quality of maternal and new-born services in the birthing centres, inadequate clinical training and insufficient skilled human resources restrained the quality of available maternity services resulting in low coverage of institutional deliveries.
"Efficient and increased investment in the public health system at all tiers is imperative to effectively reduce financial inequities of service use and ensuring optimal care for mothers and new-borns."
